1508996166 NPI number — DR. TRACY LYNN EDELMANN D.C.

Table of content: DR. TRACY LYNN EDELMANN D.C. (NPI 1508996166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508996166 NPI number — DR. TRACY LYNN EDELMANN D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDELMANN
Provider First Name:
TRACY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDELMANN
Provider Other First Name:
TRACY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1508996166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8000 BONHOMME AVE STE 409
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63105-3515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-302-0333
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8000 BONHOMME AVE STE 409
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63105-3515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-302-0333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  006482 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 188898 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: MA3182 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: MA3182001 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 43-1752340 . This is a "FED ID NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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